A Population-Based Cohort Study Examining the Long-term Risk of Repeated Surgery in Non-Helicobacter pylori-Infected PPU Patients Who Underwent Simple Closure
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The management of perforated peptic ulcer (PPU) has shifted from vagotomy/drainage to simple closure, followed by postoperative proton pump inhibitors (PPIs) and Helicobacter pylori (HP) eradication. Few studies have focused on the long-term impacts of this trend shift. We hypothesize that simple closure with PPIs is sufficient and does not carry an elevated rate of repeated surgery in non-HP-infected PPU patients.
Hospitalized PPU patients who underwent simple closure or truncal vagotomy/pyloroplasty (TVP) in the National Health Insurance Research Database (NHIRD) from 2000 to 2008 were collected. The index date was defined as the date of ulcer admission. Patients who underwent other ulcer surgeries (e.g., gastrectomy, highly or selective vagotomy), who had a history of HP infection, or who were < 18 or > 100 years old were excluded. Additionally, the distributions of postoperative nonsteroidal anti-inflammatory drug (NSAID) and PPI use were calculated using the Longitudinal Health Insurance Database (LHID).
After exclusion, a total of 66,413 patients were enrolled. There were 7232 (10.9%) patients who underwent TVP and 59,181 (89.1%) patients who underwent simple closure. The incidences of repeated ulcer-associated surgery were 5.10 and 23.05 versus 5.11 and 15.77 per 1000 person-years in the TVP cohort vs. the simple closure cohort before and after propensity score matching, respectively. When adjusted for age, sex, comorbidity, and Charlson comorbidity index score, the TVP cohort had a 68% (HR) and 66% (sHR) decreased risk compared with the simple closure cohort before propensity score matching, with a 67% decreased risk after propensity score matching in Cox proportional subdistribution hazard analysis and a 66% decreased risk in Fine-Gray proportional subdistribution hazard analysis. The LHID analysis showed a lower rate of postoperative NSAID use and a higher rate of postoperative PPI use in simple closure patients.
Our findings suggest that in the Asian population, simple closure increases the risk of repeated ulcer-associated surgery in non-HP-infected PPU patients compared with TVP patients. However, further studies are warranted.
KeywordsPerforated peptic ulcer Simple closure Vagotomy Recurrent perforation
perforated peptic ulcer
proton pump inhibitors (PPIs)
National Health Insurance Research Databases
nonsteroidal anti-inflmmatory drugs
Longitudinal Health Insurance Database
Charlson comorbidity index
gastroesophageal reflux disease
International Classification of Diseases, Ninth Revision, Clinical Modification
acquired immune deficiency syndrome
subdistribution hazard ratio
body mass index
Wu SC conceived and designed the study and wrote the initial draft of the manuscript; Chen WT participated in study design and conception; Muo CH performed the data analysis and interpretation and was involved in writing the initial draft of manuscript; Wu SC and Hsu CY performed data analysis and interpretation as well as manuscript drafting and revision. Guarantor of the article: Shih-Chi Wu, MD, PhD.
This study is supported in part by the Ministry of Health and Welfare, Taiwan (MOHW107-TDU-B-212-123004), China Medical University Hospital (DMR-107-192), Academia Sinica Stroke Biosignature Project (BM10701010021), MOST Clinical Trial Consortium for Stroke (MOST 106-2321-B-039-005), Tseng-Lien Lin Foundation, Taichung, Taiwan, and Katsuzo and Kiyo Aoshima Memorial Funds, Japan.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
Ethics Approval and Consent to Participate
For complying with the Personal Information Protection Act, the data abstracted from the chart contained no identification of patient information. All identifications of patients were replaced with surrogate numbers for research uses. This study was approved by the Research Ethics Committee at China Medical University and Hospital (CMUH106-REC3-085).
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